New patients Patient Information Patient Name Gender MaleFemale Birthdate Civil Status MarriedSingleChildOther Preferred Name Email Address Phone (Home) Phone (Work) Mobile Employer Occupation Preferred Method of Contact PhoneMobileSMS Are you of Aboriginal or Torres Straight Island Descent YesNo Insurance Information Private Health Insurance Carrier Membership Number Your Referrence No. Name of Medical Practitioner Contact Number How did you first hear of us? Friend / Relative / Word-of-mouthInternet / WebsiteHealth Insurance DirectoryYellow Pages / Phone BookDr: _____Other Dr. Other Dental History What is your present dental concern When was your last dental appointment Do you have dental problems now? YesNo If yes, please describe a. Health Are you concerned about or experiencing any of the following Sensitive to hot, cold, sweets or pressureDecay or Broken TeethBleeding Gums, Loose TeethAbility to eatBad BreathFood Catching between teethGum Recession b. Function Are you experiencing any of the following SnoringClicking or pain in the jaw pointHead, Neck or Shoulder painsGrinding or Clenching of your teeth c. Cosmetics/Aesthetics Are you dissatisfied with your teeth and appearance. YesNo Is there anything you would like to change about your smile Are you concerned particularly about any of the following Crooked, Misaligned, Crowded TeethMissing TeethDicoloured, Stained, Yellow TeethOld FillingsSpace or Gaps between your teethDiscoloured FillingsWorn TeethOld Veneers, Crowns, Bridges, DenturesGummy Smile This section is essential to us in providing safe medical treatment: Do you have any of the following? Please tick Codeine AllergyAsthmaHealing ComplicationsHeart MurmurPenicillin AllergyCancerExcessive BleedingHepatitis Type ____Sulphur AllergyDiabetesRecurrent HeadachesHigh Blood PressureOther Allergy ____DizzinessRadiation TreatmentKidney DiseaseAnaemiaEpilepsyRespiratory ProblemsLiver DiseaseArthritisFaintingTuberculosisHay FeverArtificial JointsHIVRheumatic FeverOther ____ Hepatitis Type Other Allergy Other Are you, or could you be pregnant? YesNo Do you smoke? YesNo Are your currently taking any medications or other drugs? YesNo If yes, please state? Recall Appointments — Your recall appointment will be made at the completion of treatment A SMS or Phone Call will be given one week prior to this appointment. Please let our reception know if this doesn't suit. Terms and Conditions I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I will notify the dentist of any change in my health or medication. I further consent to having my photograph taken to be replaced on my personal dental file. Signature Date 92547
